Root Cause Analysis, Part 2

Photos from http://www.csititanic.com/.

In an earlier post, I used the 5-why technique to determine the root cause of the RMS Titanic hitting an iceberg: communication error between the watchman and his officer regarding the availability of binoculars. While this is truly a root cause, it doesn't inform us why the Titanic, billed to be "unsinkable," sank in less than three hours once it hit the iceberg. So the next question is, once it hit the iceberg, why 1, why did it sink so quickly?

The answer to this first why unfolds in a new book called "What really sank the Titanic." In it, the authors present results of submarine recon showing the ship sank so quickly due to rivets popping along the six slits opened in the seams on the bow of the Titanic. So the next question, why 2, is why did the rivets pop?

Research indicates that the rivets used were poorer quality than standard, causing an easy fracture path for failure. The research was conducted on many rivet samples retrieved from the shipwreck site. Photomicrographs show the phosphate and sulphate inclusion level in these iron rivets is excessive, leading to a weaker fastening of the ship. You can see this on the scanning electron micrograph, shown below from www.csititanic.com, which shows a long slag inclusion provided a fracture path for this rivet's failure.

So the next question, why 3, is why the poor quality rivets were used?

These lower quality rivets were used because of a scarce supply of top quality rivets. Research on meeting minutes cites repeated references to shortages of "best best" quality rivets. So the next question, why 4, is why there was a scarce supply?

The shipbuilder, Harland & Wolff, was building three ships the size of Titanic at the same time. The Britannic and the Gigantic were ships in the same series as the Titanic, and all three were under construction at the same time. Which begs the final question, why 5, why were they building three huge ships at once?

This was a policy decision made by managers at Harland and Wolff. The basic motivator is the drive for profits which, in this case, trumped the need for quality. So to avoid the sinking of the Titanic, an executive at Harland and Wolff would have had to say, “no, we cannot meet this schedule and build the three ships safely with materials that are currently available, so we must delay one or two of the ships.” This would have allowed proper materials to be used and would have saved 1520 lives.

This analysis shows that most problems are the cause of policy decisions and ineffective management, not workers like watchmen or riveters. It was an officer who didn’t supply the binoculars, it was an executive who specified the wrong rivets rather than changing the schedule.
The root cause of the Titanic's sinking so quickly was an executive decision far removed from the sinking, both in space and time; As Deming said, “The problem is at the top, management is the problem.”

Ideas Change the World

Time Magazine's cover story this week is "10 Ideas That Are Changing the World." They say that "ideas are the secret power that this planet runs on." The first story is about the idea Time feels has the greatest potential to change the world, namely, that we belong to a global community and gain more by cooperation than competition. They claim "the defining challenge of the 21st century will be to face the reality that humanity shares a common fate on a crowded planet." The article calls for a new approach to global problem-solving. It's worth a read.

A new approach to problem solving... a very powerful concept that weaves in my business and community service life.

I help teams to implement a new approach to global problem solving -- by providing online meeting facilitation training.

Patterns of Crises

The direct translation of these Chinese characters, which mean crisis, is "an opportunity riding a dangerous wind." Although crises present opportunities, most crises are unwanted and we feel better off without.

In his book, Will Your Next Business Mistake Be Fatal? Avoiding a Chain of Mistakes that Can Destroy Your Organization, Robert E. Mittelstaedt, Jr. describes a pattern traced back from crises. Mittelstaedt finds that the pattern includes these components (and I quote, from the book):

"- An initial problem, often minor in isolation, that goes uncorrected
- A subsequent problem that compounds the effect of the initial problem
- An inept corrective effect
- Disbelief at the accelerating seriousness of the situation
- Generally, an attempt to hide the truth about what is going on while an attempt is made at remediation
- Sudden recognition that the situation is out of control or “in extremis” (In extremis is a Latin phrase meaning "in the furthest reaches" or "at the point of death".)
- Finally, the ultimate disaster scenario involving significant loss of life, financial resources, or both, and ultimately, the recriminations."

If this pattern seems familiar, it should, because most business problems that become crises follow this pattern. Also, the large crises our governments face can be traced back through the same pattern.

What to do, then, to avoid these crises? Clearly, the chain of escalation must be broken. The first component of the pattern is the initial problem. So many crises start out small, in a manageable scope, yet go unfixed. An effective method of problem detecting and corrective action nips these problems in the bud.

When the initial problem gets past the first wave of defence, an interacting problem often amplifies the first one. Now a real mess is brewing. If corrective action fails here, the next phase in escalation is when those responsible begin hiding the problem or downplaying its significance. This can be done through filtering information as it goes up the chain of command. A boss can work to avoid filtering by having several lines of communication to compare messages and validate what he or she is hearing. When there is a disconnect, one of the sources is either filtering information or out of touch. Regardless, this is when help is needed but somehow doesn't show up.

Next, the crisis erupts in some undeniable way. People ask, "how could this happen?" There is enough blame to go around and lessons are learned and spread throughout the organization, but the key question is, is there a system in place to root out problems in their infancy and solve them completely? If not, be ready for more "opportunities riding dangerous winds."

With years of problem solving and corrective action experience, The Flying Toolshed implements corrective action systems so crises may be avoided all together. We believe creating opportunities for our clients rather than having opportunities thrust upon them.

bob@flyingtoolshed.com

Problem Solving Approach Defined

We lead teams through a problem solving approach broken into two phases marked by different thought processes. First is the expansion phase, where problems are identified, a problem statement is created, and options are developed. Divergent thinking is required here. Next is the closure phase, where we select an option or options, action is planned and executed, and results are evaluated. Convergent thinking is required in this phase. To close the loop, the process is then repeated, and in high performing organizations, this is an ongoing cycle.*

Problem finding seems easy, because usually they jump up and bite us. Finding hidden problems is often an overlooked step in problem solving. Take for example a low grade "under the radar" quality problem. Often this problem gets a superficial fix and is forgotten. If after time, this problem becomes a repeated headache for a customer, it escalated to cost business. Finding the problems, therefore, is an overlooked step that can be crucial.

Problem stating is an important defining step. What is the problem and what is it not? Can you state succinctly what the problem really is? Often teams get this wrong and end up working on too broad a scope rather than zeroing in on the exact problem.

Option finding is the last part of the expansion phase, where potential solutions are generated. Here we go for quantity, developing as many creative ways to solve the problem as possible.

Now we switch gears to the convergent thinking with the decision of which options to pursue. This is done using data and experience from the process results. An action plan is developed and executed, and when completed, evaluation is made as to the effectiveness of the solution.

The next step, once that problem is solved, is to find the next problem. And the cycle goes on, and we generate process improvement profit.

We use this approach in solving problems of all kinds and we apply various tools to achieve resolution. We use lean and six-sigma approaches as well as 8-discipline approach. We provide strategic planning to work on longer term problems and develop new markets. We stick with our clients from start to finish, helping to implement solutions if desired. One of the first things we do with new clients is to sit down and discuss their process improvement problem or concern in a free initial consultation. Contact us at 828-505-1695.

*Adapted form Karl Albrecht's Brain Power.

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Imperiled Start Up

"Foolish consistency is the hobgoblin of small minds."
Ralph Waldo Emerson


I was in charge of a new plant start up -- a risky assignment since many launches went badly, and this was my first try at it. My responsibility was to take an empty shell of a building and populate it with machines and people, processes and systems, and generate profit.

This launch depended on implementing some unproven new technology, a red flag. The technology in question was elaborate mechanical tooling which deployed in a CNC machine to cut a precise spherical radius on the ID of a casting. To perform this feat, the CNC equipment loaded the casting, then the tool, in the shape of a cylinder with a slot cut out of the side, was inserted into the casting opening. The tool had an ingenious mechanical device to deploy the cutter from the slot using a spine-like grooved lever. The cutting was done at high speed (turning the tool), and at the end of the cycle, the tool was quickly stopped then the cutter was retracted using spring action, hiding the cutter away in the cylinder again, and the tool was pulled from the casting. Nice Idea!

We got the equipment in and set up. We hired great people. We did a lot of training. All the while, I kept hearing about broken cutters. This was troubling because it was unproven technology and the entire start up depended on success. Not only that, cutters cost over $100 each, so the budget was feeling the pain.

We talked to the experts at the toolmaker. They tried to fix the problem. They kept trying, but to no avail. Finally, after weeks and weeks of trying, it became clear that this start up was in peril.

I ordered autopsies of each broken cutter. We opened up some tools to see what was happening. The engineers were puzzled and befuddled. We were asked to start working on "Plan B," which would cost a lot in capital to retrofit our operation. Then I saw the key.

Each tool that had a broken cutter, when opened up, had several small retracting springs which had toppled in the deceleration. The centrifugal force caused the springs to fall over on their side, laying down and providing no force to retract the cutter.

A big shock-absorber spring, that's what we needed! Once we figured out how to place strong enough spring coaxial with the center line, the decelerating forces were overcome by better engineering. The funny thing was, it took a tremendous effort to convince the inventor of the technology to change it... even though the initial design was failing.

My take-away: be open to new ways of looking at things, especially if we invented something and the old way isn't working. When we invent something we are proud of, great! When improvements to that invention come along, better! Often new ideas come from the most unlikely sources, so have eyes and ears open, and minds prepared to accept the possibility of something better.

Please let me know about a time you saw an inventor learn how to improve their invention from an unlikely source...

For more information on the "imperiled start up": http://www.mmsonline.com/articles/069903.html